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The nurse has just received the change of shift report on the following clients on the labor, delivery, recovery, and postpartum unit. Which of these clients should the nurse assess first?
- A. An 18-year-old single primigravid client, in labor for 9 hours, with cervical dilation at 6 cm, 0$ station, contractions occurring every 5 minutes, and receiving epidural anesthesia.
- B. A 24-year-old multiparous client who delivered a 4,200g infant 2 hours ago, whose fundus is firm and who is having light lochia flow.
- C. A 30-year-old multigravid client who delivered a 3,500g infant 6 hours ago by cesarean section and who is complaining of abdominal pain at the incision site.
- D. A 35-year-old primigravid client, 36 weeks' gestation, who was admitted with preterm labor and is receiving magnesium sulfate therapy.
Correct Answer: D
Rationale: The client with preterm labor on magnesium sulfate requires immediate assessment due to the risk of toxicity and preterm delivery complications.
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Which neurological complication can occur when a vest restraint is too tight around the client's body?
- A. Strangulation
- B. Skin breakdown
- C. Skin pallor
- D. Numbness
Correct Answer: A
Rationale: A too-tight vest restraint can cause strangulation, a life-threatening complication, by restricting breathing or neck movement.
The nurse is caring for a client with a history of glaucoma. Which of the following medications should the nurse expect to administer?
- A. Timolol (Timoptic).
- B. Atropine (Isopto Atropine).
- C. Pilocarpine (Isopto Carpine).
- D. Latanoprost (Xalatan).
Correct Answer: A, C, D
Rationale: Timolol, pilocarpine, and latanoprost are used to reduce intraocular pressure in glaucoma. Atropine is contraindicated as it increases pressure.
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
- A. Normal sinus rhythm.
- B. Sinus tachycardia.
- C. Atrial fibrillation.
- D. Ventricular tachycardia.
Correct Answer: C
Rationale: Without the strip, atrial fibrillation is assumed for its common occurrence and need for monitoring in a test context.
A client with a diagnosis of systemic lupus erythematosus (SLE) is prescribed hydroxychloroquine (Plaquenil). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Retinal toxicity.
- C. Hypoglycemia.
- D. Hair loss.
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal toxicity, requiring regular eye exams to monitor for vision changes.
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are typically documented as length x width x depth (2 cm x 4 cm x 3 cm), but based on options, 12 cm may reflect a calculation error; correct documentation is individual measurements.